Revised May 2011. Date: ______. Last Name: First Name: Middle: Student ID#:
DOB: Phone: Sex: Address: City: State: Zip: Medical History. Abdominal Pain.
Health Sciences Department HEALTH APPRAISAL Date: _____________
(This side to be completed by applicant)
Last Name: Student ID#:
First Name: DOB:
Address:
Middle: Phone:
City:
Sex: State:
Zip:
Medical History Abdominal Pain Yes No Hernia Yes No Allergies Yes No Kidney Disease Yes No If yes, list: ________________________ High Blood Pressure Yes No Anemia Yes No Liver Disease/Hepatitis Yes No Anxiety Yes No Surgery Yes No Asthma Yes No Date & Type: ______________________ Back Pain/Injury Yes No Thyroid Disease Yes No Depression Yes No Ulcers/Gastritis/GERD Yes No Diabetes Yes No Vision Problems Yes No Eating Disorder Yes No Smoke Yes No Epilepsy/Seizure Yes No Packs per week: ____________________ Headaches/Migraines Yes No Alcohol Use Yes No Head Injury/Concussion Yes No Drinks per week: ___Drinks per month:____ Hearing Problems Yes No Drug Use Yes No Heart Disease/Murmur Yes No Type/Frequency: ____________________ Other: __________________________________________________________________________ Current medications / herbs / supplements:
Yes
No
List:
________________________________________________________________________________ Who is your primary care physician? _________________________________________________ Have you ever been hospitalized?
Yes
No
If yes, give date and reason for hospitalization: Have you ever failed a physical examination?
Yes
No
If yes, please explain reason(s): This information may be shared with the department requesting the Health Appraisal and/or with the medical facility to which I may be assigned. The above information is true and correct to the best of my knowledge.
Signature Over Please!
Revised May 2011
Date
PHYSICAL EXAMINATION (This side to be completed by Physician/Examiner) Name:
ID#:
Height:
Weight:
B/P:
Pulse:
Resp:
LMP:
Vision Screening:
Right: 20/
Left: 20/
Both: 20/
With glasses:
Right: 20/
Left: 20/
Both: 20/
Hearing Screening:
Right:
Left
TB SCREENING Two-Step PPD Skin Test is required for all Health Science students. (Students with a history of a positive TB test must submit a radiology report of a chest x-ray taken within 6 months.) TB Mantoux Test given date:
Results date:
Induration:
TB Mantoux Test given date:
Results date:
Induration:
Chest X-ray date:
Chest X-ray results: (Copy of Reading Report required.)
VACCINATIONS (Students must have documentation of vaccinations or have titers demonstrating immunity.) Vaccination
Date
Results
Vaccination
Date
Results
MMR #1
N/A
Hepatitis B #1
N/A
MMR #2
N/A
Hepatitis B #2
N/A
Rubella Titer*
Hepatitis B #3
N/A
Mumps Titer*
Hepatitis B Surface Antibody Titer*
Rubeola Titer*
Varicella* N/A
Tdap**
**Must have been received within five (5) years.
*Copy of blood tests results required Proof of seasonal flu/H1N1 vaccination must be submitted annually by October 15
Alert, well appearing, no apparent distress. Canal without tenderness or exudate. TMs good landmarks/light reflex, no erythema. Patent nares; no sinus tenderness to palpation. No erythema, exudate; no tonsillar enlargement. Supple, no adenopathy; no thyromegaly. Equal breath sounds; no respiratory distress; no wheezes, rhonchi or rales. Regular rhythm; no murmurs, gallops or rubs. Active BS; soft; no tenderness, guarding, masses or organomegaly; no CVA tenderness. No rashes, petechiae or other lesions. DTRs +2 bilaterally; strength 5+/5+; Romberg negative. Straight, full ROM; non-tender to palpation Accepted for Program: Yes
